Ron Singh is the senior vice president of cost containment for Gainwell.

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For healthcare organizations, the coordination of benefits (COB) process, also known as third-party liability (TPL), presents an opportunity to maximize cost savings and ensure payment accuracy. Yet navigating COB can quickly become burdensome and complex, requiring payers to juggle various data sources and set aside significant administrative and technical resources. 

To mitigate these challenges, there are various COB technology solutions that enable healthcare organizations to identify, verify, and communicate existing coverage for members at the point of enrollment or point of prior authorization. This way, plans can help accurately and effectively coordinate care, boost savings, and ensure accurate reimbursements.

There is no lack of available COB solutions on the market, and the trouble is often identifying which option is the best fit for your organization. For optimal results, look for the following six elements in a COB solution to have the most success.

Data is the underlying driver of successful coordination of benefits, and a robust relevant data pool is essential for the most accurate results. Ensuring the upkeep of known third-party liability (TPL) data is essential for the prevention of member and provider abrasion. Additionally, to have a 360-degree view of member benefits, all other health insurance (OHI) information is also required to identify all potential coverage sources. Looking for a solution that provides data across different plan types will lead to the best and most accurate COB results.

A strong COB solution operates at multiple points throughout the healthcare journey. While post-payment recovery will always have a primary role in COB, for the most effective solution, look for technology that offers enrollment, pre-payment and post-payment COB components. This will work to diminish any potential gaps in payment while reducing administrative costs and increasing financial savings.

As noted, robust data is essential for successful COB. Yet to identify cost savings and coordinate care, patient health data needs to be shared across different systems and organizations to yield the best results. A solution that is interoperable with an organization's eligibility or claims management systems will ensure that data can be widely communicated and shared to maximize COB efforts.

Automation and machine learning continues to play a prominent role in healthcare technology, and COB is no exception. The most comprehensive COB solutions leverage advanced data mining, data matching, and analytics to identify alternative payment options in real-time. By leveraging big data, solutions can automate the process by identifying claim characteristics such as claim type, employer group, and procedure code, to distinguish claims with the highest likelihood of recovery.

Reporting features and metrics are important capabilities for a COB solution to track progress and quantify the program’s success. Through visibility into performance drivers, plans can measure and track emerging trends to fine tune strategy and inform decision making.

To streamline the COB process, effective communication between payers and providers is often needed when working on more complex member cases. To increase efficiency and enhance the speed of recovery, features such as customized interfaces, dedicated online portals and direct connections are beneficial to open lines of communication between payers and providers and ease the process of reviewing and submitting claims electronically. This of course is supplemented with deep rooted relationships and staff expertise.

In today’s technology-fueled world, there is a surplus of options when it comes to choosing the latest solutions, which complicates the selection process. When it comes to coordination of benefits, having an integrated and data-driven solution that acts as a single source of truth for all TPL information is essential for reducing costs and administrative burden while simultaneously improving benefits and continuity of coverage for recipients.

Ron Singh

Articles

The Top Six Qualities of an Effective Coordination of Benefits Solution